Extracorporeal life support in trauma: Indications and techniques.

BACKGROUND: Clarity about indications and techniques in extracorporeal life support (ECLS) in trauma is essential for timely and effective deployment, and to ensure good stewardship of an important resource. Extracorporeal life support deployments in a tertiary trauma center were reviewed to understand the indications, strategies, and tactics of ECLS in trauma. METHODS: The provincial trauma registry was used to identify patients who received ECLS at a Level I trauma center and ECLS organization-accredited site between January 2014 and February 2021. Charts were reviewed for indications, technical factors, and outcomes following ECLS deployment. Based on this data, consensus around indications and techniques for ECLS in trauma was reached and refined by a multidisciplinary team discussion. RESULTS: A total of 25 patients underwent ECLS as part of a comprehensive trauma resuscitation strategy. Eighteen patients underwent venovenous ECLS and seven received venoarterial ECLS. Nineteen patients survived the ECLS run, of which 15 survived to discharge. Four patients developed vascular injuries secondary to cannula insertion while four patients developed circuit clots. On multidisciplinary consensus, three broad indications for ECLS and their respective techniques were described: gas exchange for lung injury, extended damage control for severe injuries associated with the lethal triad, and circulatory support for cardiogenic shock or hypothermia. CONCLUSION: The three broad indications for ECLS in trauma (gas exchange, extended damage control and circulatory support) require specific advanced planning and standardization of corresponding techniques (cannulation, circuit configuration, anticoagulation, and duration). When appropriately and effectively integrated into the trauma response, ECLS can extend the damage control paradigm to enable the management of complex multisystem injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

5 Slides in 5 Minutes: Incorporating CanMEDS Competencies on Acute Care Surgery.

BACKGROUND: The University of British Columbia (UBC) Division of General Surgery developed an initiative entitled "5-in-5s" to improve educational opportunities on the Acute Care Surgery (ACS) service. We examined whether 5-in-5s are felt to be a valuable teaching tool, and evaluated their ability to incorporate CanMEDS competencies within the General Surgery program. METHODS: A web-based survey was distributed to all general surgery trainees and staff on ACS that have participated in 5-in-5s. RESULTS: A total of 37 responses were collected (62% response rate). All respondents felt 5-in-5s were valuable overall. Four of the seven CanMEDS competencies were evaluated. About 100% felt their knowledge was positively impacted by presenting, and 80% by attending alone. About 71% of respondents agreed that 5-in5s provided opportunities for health advocacy, 50% for collaboration, and 36% for leadership. CONCLUSION: We identified 5-in-5s as a valuable teaching method and a novel approach to integrate CanMEDS competencies into ACS training.

Tele-mentored damage-control and emergency trauma surgery: A feasibility study using live-tissue models.

BACKGROUND: Damage-control and emergency surgical procedures in trauma have the potential to save lives. They may occasionally not be performed due to clinician inexperience or lack of comfort and knowledge. METHODS: Canadian Armed Forces (CAF) non-surgeon Medical Officers (MOs) participated in a live tissue training exercise. They received tele-mentoring assistance using a secure video-conferencing application on a smartphone/tablet platform. Feasibility of tele-mentored surgery was studied by measuring their effectiveness at completing a set series of tasks in this pilot study. Additionally, their comfort and willingness to perform studied procedures was gauged using pre- and post-study surveys. RESULTS: With no pre-procedural teaching, participants were able to complete surgical airway, chest tube insertion and resuscitative thoracotomy with 100% effectiveness with no noted complications. Comfort level and willingness to perform these procedures were improved with tele-mentoring. Participants felt that tele-mentored surgery would benefit their performance of resuscitative thoracotomy most. CONCLUSION: The use of tele-mentored surgery to assist non-surgeon clinicians in the performance of damage-control and emergency surgical procedures is feasible. More study is required to validate its effectiveness.

Intentional injury and violence in Cape Town, South Africa: an epidemiological analysis of trauma admissions data.

BACKGROUND: Injury is a truly global health issue that has enormous societal and economic consequences in all countries. Interpersonal violence is now widely recognized as important global public health issues that can be addressed through evidence-based interventions. In South Africa, as in many low- and middle-income countries (LMIC), a lack of ongoing, systematic injury surveillance has limited the ability to characterize the burden of violence-related injury and to develop prevention programmes. OBJECTIVE: To describe the profile of trauma presenting to the trauma centre of Groote Schuur Hospital in Cape Town, South Africa - relating to interpersonal violence, using data collected from a newly implemented surveillance system. Particular emphasis was placed on temporal aspects of injury epidemiology, as well as age and sex differentiation. DESIGN: Data were collected prospectively using a standardized trauma admissions form for all patients presenting to the trauma centre. An epidemiological analysis was conducted on 16 months of data collected from June 2010 to October 2011. RESULTS: A total of 8445 patients were included in the analysis, in which the majority were violence-related. Specifically, 35% of records included violent trauma and, of those, 75% of victims were male. There was a clear temporal pattern: a greater proportion of intentional injuries occur during the night, while unintentional injury peaks late in the afternoon. In total, two-third of all intentional trauma is inflicted on the weekends, as is 60% of unintentional trauma. Where alcohol was recorded in the record, 72% of cases involved intentional injury. Sex was again a key factor as over 80% of all records involving alcohol or substance abuse were associated with males. The findings highlighted the association between violence, young males, substance use, and weekends. CONCLUSIONS: This study provides the basis for evidence-based interventions to reduce the burden of intentional injury. Furthermore, it demonstrates the value of locally appropriate, ongoing, systematic public health surveillance in LMIC.

Access to trauma systems in Canada.

BACKGROUND: Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care. METHODS: A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care. RESULTS: In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions. DISCUSSION: Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.

Analyzing the effects of place on injury: Does the choice of geographic scale and zone matter?

BACKGROUND: Recent studies have shown that the morbidity and mortality associated with injury of pedestrians are inversely related to socio-economic status (SES). However, in drawing inferences from this association, investigators have paid little attention to the modifiable artifacts related to scale and how the data are partitioned. The purpose of this population-based study was to identify the relation between SES and incidence patterns of pedestrian injury at 4 different geographic scales. METHODS: We used a Poisson generalized linear model, stratified by age and sex, to analyze the relation between each of 4 area measures of SES and incidence patterns of pedestrian injuries occurring in metropolitan Vancouver between 1 January 2001 and 31 March 2006. The 4 area measures of SES were based on boundaries of dissemination areas, census tracts, custom-defined census tracts (generated by reassignment of dissemination area boundaries by means of a geographic information system) and census subdivisions of the Canadian census. We measured the SES of the location where the injury occurred with the Vancouver Area Neighbourhood Deprivation Index. RESULTS: A total of 262 injuries in adults (18 years of age or older) were analyzed. Among adult men, the odds ratio (OR) for injury of pedestrians at the scale of dissemination area was 4.93 (95% confidence interval [CI] 2.89-8.42) for areas having the lowest SES relative to those with the highest SES. For the same population, the OR for injury was lower with increasing aggregation of data: 2.33 (95% CI 1.45-3.74) when census tracts were used, 3.26 (95% CI 2.06-5.16) when modified census tracts were used and 1.27 (95% CI 0.47-3.45) when census subdivisions were used. Among adult women, the OR for pedestrian injury by SES was highest at the scale of census subdivision within medium-low SES areas (4.33, 95% CI 1.23-15.22). At the census subdivision scale, the relation between SES and incidence pattern of injury was not consistent with findings at smaller geographic scales, and the OR for injury decreased with each increase in SES. INTERPRETATION: In this analysis, there was significant variability when different administrative boundaries were applied as proxy measures of the effects of place on incidence patterns of injury. The hypothesized influence of SES on prevalence of pedestrian injury followed a statistically significant socio-economic gradient when analyzed using small-area boundaries of the census. However, researchers should be aware of the inherent variability that remains even among the more homogenous population units.

Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit.

BACKGROUND: Despite the evidence that enteral feeding reduces morbidity in critically ill patients and is preferred to parenteral nutrition, the delivery of enteral nutrition (EN) is often inadequate. The purpose of this study was to determine whether implementation of an evidence-based nutrition support (NS) protocol could improve EN delivery. METHODS: An NS protocol incorporating available scientific evidence; data from a retrospective survey of 30 intensive care unit (ICU) patients; and input from dietitians, intensive care physicians, surgeons, nurses, and pharmacists was developed. The impact of this protocol was evaluated prospectively in 123 consecutive adult patients admitted to a multisystem ICU who were eligible for EN. RESULTS: The percentage of patients who received at least 80% of their estimated energy requirements during their ICU stay increased from 20% before implementation of the NS protocol to 60% after implementation (p < .001). After adjusting for confounders, those in the postimplementation group received significantly more kcal/kg/d than the preimplementation group (3.71 kcal/kg/d; 95% confidence interval, 1.64 to 5.78; p = .001). Parenteral nutrition use [corrected] was reduced in the postimplementation group (1.6 vs 13%, p = .02). There was no difference in time to initiation of enteral nutrition between groups (1.76 days preprotocol vs 1.44 days postprotocol implementation, p = .9). CONCLUSIONS: The development and use of an evidence-based NS protocol improved the proportion of enterally fed ICU patients meeting their calculated nutrition requirements.